Neuropsychiatric sequelae in TBI/concussion
Up to 2 million children sustain sport and recreation related concussions every year, and while most recover without difficulty within a few weeks, some develop persistent symptoms with functional and even structural brain changes. These changes have been shown to lead to decreased quality of life up to 1 year after the injury. This narrative review of the literature looked to synthesize the current evidence on the neuropsychiatric sequelae of pediatric TBI and concussion.
What did they find?
A little pathophys:
TBI alters stress reactivity; the buzz word appears to be “fronto-limbic disconnection.” This contributes to anxiety, depression and anhedonia. Hippocampal volume reduction has been shown in patients with multiple concussions. These changes are only seen on Diffusion Tensor Imaging (DTI)- a special MRI that shows 3-D images of neural pathways.
What can we do?
Bottom line:
Pediatric concussions are common and a subset of children develop persistent neuropsychiatric symptoms and increased risk of future mental health disorders. Emphasis should be placed on patient/family education, mental health involvement, objective assessment, and a cautious return-to-play approach, especially in those at higher risk.
What did they find?
- Injury severity, age, gender, and socioeconomic status all affected outcomes with females experiencing more symptoms than males.
- Early and/or repeated injury leads to increased risk for a future psychiatric diagnosis (including attention-deficit/hyperactivity disorder, conduct or oppositional defiant disorder, substance use disorders, bipolar disorder and mood disorders)
- After TBI, there can be as much as a 50% increase in self harm and need for psychiatric hospitalization
- All of these findings are more common in those with genetic predisposition, multiple TBIs, or younger age at time of injury
- Multiple TBIs are associated with slower recovery and greater symptom burden
A little pathophys:
TBI alters stress reactivity; the buzz word appears to be “fronto-limbic disconnection.” This contributes to anxiety, depression and anhedonia. Hippocampal volume reduction has been shown in patients with multiple concussions. These changes are only seen on Diffusion Tensor Imaging (DTI)- a special MRI that shows 3-D images of neural pathways.
What can we do?
- Most importantly, talk to families about the neuropsychiatric sequelae of TBI/concussion. Encourage early mental health involvement. Educate on the risk associated with multiple injuries.
- Its important to start measuring objective data early with the SCAT6. This should ideally be done within 72 hours of injury; it’s a bit too extensive for the ED, but could be included in the paperwork for the patient and instructed to be filled out in follow up with PCP
- Consider a more conservative return-to-sport in those with a history of prior TBI/concussion
- Discuss how sleep and mood are important early, therefore it will be important to balance staying social without overdoing it
- Consider follow up in a concussion clinic
Bottom line:
Pediatric concussions are common and a subset of children develop persistent neuropsychiatric symptoms and increased risk of future mental health disorders. Emphasis should be placed on patient/family education, mental health involvement, objective assessment, and a cautious return-to-play approach, especially in those at higher risk.
